What is the best course of treatment for a patient with multilevel degenerative disc disease, presenting with back pain and MRI findings indicating disc dehydration, disc height loss, and endplate marrow change, with no evidence of osseous edema or compression deformity?

Management of Multilevel Thoracic Degenerative Disc Disease with Back Pain

Initial Conservative Management is the First-Line Treatment

Conservative therapy for at least 6 weeks to 3 months is mandatory before considering any surgical intervention for multilevel degenerative disc disease without stenosis, neural compression, or instability. 1

Comprehensive Conservative Protocol Required

• NSAIDs are the first-line analgesic for axial back pain from degenerative disc disease 2
• Formal structured physical therapy for 6 weeks minimum is required, not just home exercises or general activity 1, 3
• Activity modification without complete bed rest - patients should remain active as tolerated rather than prescribed bed rest 2
• Muscle relaxants for spasm may provide symptomatic relief during acute exacerbations 2
• Heat/cold therapy as needed for symptomatic relief 2

Critical Distinction: Your MRI Shows NO Surgical Indications

The MRI findings are crucial here - there is no canal stenosis, no neural foraminal narrowing, no compression deformity, and no evidence of instability at any level. These findings mean:

• Disc protrusions without stenosis or neural compression do not require surgery 1
• Degenerative disc disease alone (disc dehydration, height loss, endplate changes) without stenosis or spondylolisthesis is not a surgical indication 1
• The annular fissures noted on MRI are poorly correlated with pain and do not predict surgical success 1

When Fusion Might Be Considered (Not Applicable to Your Case)

Lumbar fusion is only recommended for 1- or 2-level degenerative disc disease without stenosis or spondylolisthesis after failed conservative treatment - not for multilevel thoracic disease 1. The evidence supporting fusion is:

• Grade B recommendation exists only for lumbar spine with 1-2 levels of degenerative disc disease after comprehensive conservative failure 1
• No evidence supports fusion for multilevel thoracic degenerative disc disease as described in your MRI 1
• Fusion requires documented instability (spondylolisthesis) or stenosis requiring decompression - neither of which you have 1, 3

Why Surgery is NOT Indicated in Your Case

Multiple critical criteria are absent:

• No spinal stenosis - your MRI explicitly states "without canal stenosis" at every level 1, 3
• No neural foraminal narrowing - stated at every evaluated level 1, 3
• No spondylolisthesis or instability - no mention of any listhesis or dynamic instability 1, 3
• Thoracic location - the evidence for fusion applies to lumbar spine, not thoracic 1
• Multilevel disease - even in the lumbar spine, fusion is only recommended for 1-2 levels, not multilevel disease 1

Alternative to Fusion: Intensive Rehabilitation

If conservative therapy fails, intensive rehabilitation with cognitive behavioral therapy shows equivalent outcomes to fusion for chronic low back pain without stenosis or instability 1. This represents a Grade B alternative recommendation 1.

Components of Comprehensive Rehabilitation:

• Structured physical therapy program incorporating core stabilization 2
• Cognitive behavioral therapy to address pain catastrophizing and functional limitations 1, 3
• Multidisciplinary pain management if symptoms remain refractory 3

Critical Pitfalls to Avoid

• Do NOT pursue surgical consultation without completing 6 weeks minimum of formal physical therapy 1, 3
• Do NOT interpret degenerative MRI changes as automatic surgical indications - disc dehydration, height loss, and endplate changes are extremely common and poorly correlated with pain 1
• Do NOT assume multilevel disc protrusions require surgery - without stenosis or neural compression, these are incidental findings 1
• Do NOT order repeat imaging before 6 weeks unless progressive neurological deficits develop 2

Monitoring Timeline

• Review progress within 2 weeks of initiating conservative treatment to ensure compliance and adequate pain control 2
• Continue conservative management for at least 6 weeks before considering any escalation 2
• Reassess at 3 months - if significant improvement has not occurred, consider intensive rehabilitation program with cognitive therapy as an alternative to continued conservative care 1

The Incidental Lipoma Finding

The 1.8 cm right posterior chest wall intramuscular lipoma requires no immediate intervention - this is a benign finding that can be monitored clinically. If it becomes symptomatic or enlarges significantly on future imaging, surgical excision can be considered, but this is unrelated to your back pain.